The prevalence of diabetes in the United States has been steadily increasing and has now reached pandemic proportions.1,2 It is estimated that in 2010, 25.6 million people ≥ 20 years of age and 10.9 million people ≥ 65 years of age had diagnosed or undiagnosed diabetes.3 It also has been estimated that ∼ 1.9 million people ≥ 20 years of age were newly diagnosed with diabetes in 2010.
In adults, type 2 diabetes, a condition that can be prevented,3 accounts for 90–95% of all diagnosed cases.4 Although type 2 diabetes is not common in the younger population (≤ 20 years of age), there is some evidence that this age-group is still at risk. A recent report from the Centers for Disease Control and Prevention indicated that the rate of diabetes onset is greater among youth aged 10–19 years compared to their younger (< 10 years of age) counterparts.3 In addition to the current high incidence of diabetes in adults, it has been estimated that 79 million individuals ≥ 20 years of age have pre-diabetes, a condition that may lead to diabetes.3
In addition to the serious health complications diabetes can cause, medical expenses for individuals who have this condition are more than two times higher than for individuals without the disease. In 2007, it was estimated that the costs of diabetes in the United States were $174 billion, and it was projected that in 2010, there would be 465,000 new cases of diagnosed diabetes among people 20–44 years of age.3
The high prevalence and social cost of type 2 diabetes calls for health care professionals to target individuals at an early age for education about how to delay or prevent the onset of diabetes. It is particularly important to target college students because it has been found that 70% of individuals in this population tend to gain weight during their first year of school.5 Because the association between elevated BMI and diabetes is well established, college students who are overweight or obese and those with pre-diabetes could benefit from diabetes education at an early age.6 By the same token, college students who are not overweight or obese could also benefit from diabetes education because it has been reported that individuals in this population often engage in poor nutritional practices7 and frequently lead sedentary lives.8 It has also been noted that, by the end of the senior undergraduate year, the prevalence of obesity among college students increases markedly.9
The results of a study8 conducted in spring 2008 of 83,070 students from different colleges indicated that 23.3% of the sample did not exercise, 14.3% exercised only once a week, 16.9% exercised 2 days a week, and 16.8% exercised 3 days a week. In addition, 34.1% indicated they were slightly overweight, and 4.1% reported being very overweight. Only 8.5% reported eating five or more servings of fruits and vegetables per day.
These physical activity levels and dietary patterns do not meet the recommendations of health professionals10,11 and could pose a significant problem for some college students who might already be at risk for type 2 diabetes. For example, 61.06% of a sample of 660 college students reported a family history of type 2 diabetes in a first- or second-degree relative or both(Sealey-Potts C, Reyes-Velázquez W unpublished observations). This presents a potential problem because family history is significantly associated with the onset of diabetes in the U.S. population.12
Given the high prevalence of diabetes and college students' eating and physical activity habits, it is important to develop interventions aimed at educating this population about diabetes prevention. Early education is necessary because balancing physical activity13 with a healthful diet is good for managing weight and promoting overall health11 and can also help prevent type 2 diabetes.14 To educate college students about type 2 diabetes prevention, it is necessary to first identify how they perceive this disease and what elements would make prevention messages effective.
It has been reported that individuals tend to believe that the chance of something negative happening to them is less likely than the chance that it will occur to others.15 The presence of this optimistic bias among college students was supported by a study about unrealistic optimism and risk perception of type 2 diabetes onset (Reyes-Velázquez W, Sealey-Potts C, unpublished observations). In this study, researchers found that the number of college students who thought their peers were at risk for type 2 diabetes was higher than the number of participants who saw themselves as being at risk for the same disease.
Convincing people to adopt healthy behaviors may be more challenging if they believe they are either not susceptible to a disease or less susceptible than others.16 Moreover, optimistic bias may result from cognitive misjudgments because prevention campaigns can create a stereotype of high-risk individuals, causing some individuals at risk to incorrectly conclude that their own risk is below average.16 Consequently, identifying what types of prevention messages would work best for college students is crucial.
Behavior modification theories such as the Health Belief Model, the Transtheoretical Model, and the Theory of Planned Behavior are often used in health interventions.17,18 However, it has been stated that multiple theories should be combined to design the strongest interventions, while keeping in mind how culture, context, and health problems can affect theoretical applications and the execution of the program.17 Hence, using persuasive messages is an alternative approach to motivating individuals to modify behaviors.
Fear appeals and positive affect messages have been used to promote better health. Fear appeals are persuasive messages that emphasize the harmful physical or social consequences of failing to comply with message recommendations.19 The effectiveness of fear appeals often depends on the structure of the message. An effective fear appeal must include a threat, evidence suggesting that a person is specifically vulnerable to the threat, and solutions that are easy to perform and are effective. The assumption is that a heightened sense of fear will lead to behavior change.20
Positive affect messages include a subjective feeling or mood component.21 Messages that have affective and rational components are called emotional benefit appeals. When designing this type of message, it is expected that message recipients will comply with the message to obtain the benefits of the information presented. For example, a message containing an emotional benefit appeal can encourage the audience to eat well by showing healthy people engaging in fun activities. A connection is created in minds of the audience between eating well and having fun.
This study is part of a larger project investigating how to design diabetes prevention messages aimed at college students that could be disseminated through social networking Internet sites. This phase of the project has two goals. First, this study used a qualitative methodology to examine college students' perceptions of type 2 diabetes. Second, type 2 diabetes prevention messages using fear appeals and emotional benefit appeals were tested to identify which types of propositions should be used in a diabetes prevention campaign targeting college students.
This study was conducted in fall 2010 at a southern university. To conduct focus groups, which are also known as group interviews,22 after receiving approval from the institutional review board, three research assistants recruited participants on campus using criterion sampling. This sampling approach reviews and studies cases that meet some criterion of importance set beforehand.23 To meet our sampling parameters, students had to be at least 18 years of age and indicate they use social networking Internet sites. On the day of the focus group, participants were asked to read an informed consent form. Then, demographic information was collected anonymously.
Following the recommendation that having 6–10 participants in each focus group generates more information than each participant would provide in an individual interview,22 10 individuals were assigned to each group. Three focus groups were conducted because it has been recommended that, optimally, projects should consist of three to five groups.22
In addition, the third group was not producing new insights, which indicates that the goal of saturation was met. Saturation has been defined as the point at which new data collected do not produce new insights.22
A moderator experienced in discussing health topics conducted all the group interviews. At the conclusion of each focus group, participants received a $10.00 giftcard from a local store as an incentive. To ensure full focus groups of 10 individuals, students were over-recruited. An individual who did not get to participate in the study because there were already 10 people in a group received $10.00 and was dismissed.
A funnel-based interview was designed to emphasize free discussion first and then move toward a more structured discussion of specific questions.22 Three type 2 diabetes prevention messages were designed using desktop publishing software. Participants were handed a hard copy of the messages to review during the group interviews. Then, they were shown the message that had the fear appeal on a non-public Facebook profile. The interviews were audiotaped, transcribed verbatim, and imported into Nvivo 8. A codebook was developed. A team of two investigators coded the transcripts.
Three focus groups of 10 participants each were conducted. The majority of the participants were female (73.3%, n = 22). The mean age was 20.67 ± 2.21 years. Forty-seven percent of the participants were African American, 33.3% were non-Hispanic white, and 20.0% were Hispanic. Participants were classified as freshmen (10.0%), sophomores (30.0%), juniors (26.7%), or seniors (33.3%).
At the beginning of each group interview, participants were asked to mention any health problems they were concerned about, even if they did not have any immediate personal health problems. The subjects mentioned diabetes, cancer, heart disease, alcoholism, breast cancer, arthritis, and high blood pressure as health concerns. A typical participant response was, “I'm concerned about diabetes because it runs in my family, but also, because I'm a college student, I'm worried about swine flu and things like that.”
General diabetes knowledge
Participants were asked to describe type 2 diabetes. Table 1 shows some of the findings. Participants mostly described this condition by discussing low blood glucose and how to manage the condition. Most participants indicated that diabetes is a disease that has to do with sugar in the body and that it is hereditary.
Participants were asked to identify type 2 diabetes risk factors, how the disease develops, and how it is diagnosed. Although some participants mentioned that physicians look into individuals' family history and lifestyle to identify who has this condition, they were not able to explain what causes type 2 diabetes or identify all the risk factors. Participants indicated that it develops by not eating right and by being overweight. They also provided incorrect information about how it is diagnosed. Some of them talked about lifestyle, but they were not able to specify what would be a healthy lifestyle to prevent the onset of diabetes. As one participant said, “I really don't have an idea.” Another participant said, “I know when you go to get your blood work done to get diagnosed, you have to drink a very syrupy... I don't know what it's called, but it's something [that], after you drink it, they measure your blood levels and that's the indicator.”
Participants were then asked to identify type 2 diabetes symptoms. They mentioned fatigue, seizures, getting cold easily, sleeping excessively, tingling in your fingers, stress, craving sugar, getting moody, blurred vision, frequent urination, tremors, dizziness, and cataracts. Some students indicated they did not know what the symptoms are, but one of them said, “Your body, like, shuts down.”
After asking students about their diabetes knowledge, they were asked whether they were concerned about it. Students who had family members with diabetes indicated concern, but some others said they were not concerned.
Knowledge of diabetes prevention
To identify what students know about type 2 diabetes prevention, the researchers asked students to talk about nutrition and physical activity by creating drawings related to the theme “type 2 diabetes and lifestyle.” Although students mostly talked about good and bad foods, they were not able to identify such foods. The participants primarily talked about sweets, not being able to eat certain food such as hamburgers and fries, exercise in general, and diabetes care. Additional detail about participants' comments can be found in Table 1.
Participants were asked what kind of exercise people can do to prevent type 2 diabetes. They mentioned walking, running, bike riding, and cardiovascular exercise. One participant talked about different ways to engage in physical activity, saying, “I think cardio, but I don't really like to run; I swim. But [I would say] anything that will get your heart pumping just like [it] cleanses your body.” Only two participants mentioned time, indicating that one should exercise for at least 30 minutes per day. Another student gave an idea about ways to exercise, saying, “I would say change. Instead of driving everywhere, walk more. Instead of taking the elevator, take the stairs.”
Effectiveness of prevention materials
To gain a better understanding of how to design effective type 2 diabetes educational materials for college students, participants were asked to describe communication formats that should be used to educate them about diabetes prevention. Participants mostly talked about organizing events and using different types of media such as campus media, Facebook, and e-mail to disseminate information. Some of them stated that, on their campus, events would be the best way to reach out to students. Others suggested conducting screenings and having students with diabetes, physicians, and professors talk about the disease. They also suggested teaming up with student organizations such as sororities and fraternities when trying to educate students about diabetes prevention.
Regarding message content, participants indicated that they would like to learn about symptoms, prevention, and who to talk to if they think they have diabetes. They also said it would be useful to have a description of the life of somebody who has diabetes. Table 2 shows some examples of participants' suggestions regarding prevention material and message content.
Design of prevention messages
To identify how diabetes prevention messages targeting college students should be designed, positive affect messages and fear appeals were explained to the participants. Then, participants were exposed to two gender-specific messages containing positive affect messages and one message that included a fear appeal. After analyzing the messages, participants were asked which kind of message should be designed for college students.
The first message tested explained the possibility of risky pregnancies and the increased risk of having a baby with birth defects because of diabetes. The message encouraged readers to take control of their lives by eating a healthy diet and engaging in physical activity at least three times a week for 30 minutes each time. There were different reactions to this message. Some participants said they would not pay attention to the message because they are not planning to have children in the near future.
The second message described erectile dysfunction as a consequence of having type 2 diabetes. Like the previous message, this one also encouraged readers to eat a healthy diet and engage in physical activity. Participants' reactions to this message mostly depended on whether the information was relevant to them.
The third message was based on a fear appeal. It showed a foot with gangrene. This message said, “This might be your future. Type 2 diabetes can do this to you.” The message then said there is hope because this condition can be prevented and explained what students can do to prevent diabetes. Table 2 includes more participant comments.
After analyzing the messages, participants indicated what kind of message they would prefer. Some preferred messages that focus on the positive. In addition to talking about the content, participants also commented on the graphic design. Students disliked black and white layouts with color pictures. Table 3 includes participant comments about message preferences and graphic design.
To help determine what types of diabetes prevention messages should be used for college students, participants in these focus groups described their perceptions of type 2 diabetes and analyzed prevention messages that used either fear appeals or positive affect messages. Although students expressed a range of viewpoints, similar themes predominated within the three focus groups.
According to participants, diabetes is hereditary, and those who are at risk for diabetes because their relatives have it can do nothing to prevent it. This finding is important because, although this study did not concentrate on ethnic differences, it is necessary to point out that a high percentage of the sample was African American and Hispanic. It has been documented that these groups are at a higher risk for type 2 diabetes.24,25 Although genetics is a significant risk factor for type 2 diabetes, heredity alone is not generally sufficient to cause diabetes in the absence of environmental triggers.25
The students also provided erroneous information about the symptoms and treatment of type 2 diabetes. It is therefore advisable to design interventions to educate college students from different ethnic backgrounds about type 2 diabetes risk factors, how to identify symptoms, and when to seek medical attention.
Reducing future morbidity and mortality26 resulting from diabetes, preventing its onset,27 and detecting type 2 diabetes at an early stage are all crucial. Lifestyle modification such as weight loss, exercise, and a healthful diet can help prevent type 2 diabetes.28 Because some college students do not meet exercise and dietary recommendations,6–11 it is necessary to develop targeted diabetes prevention interventions concentrating on nutrition and physical activity.
Some participants mentioned that correct food selection is a problem for them. Therefore, they should be taught how to gradually make changes to modify their eating habits.
An important question to investigate when designing interventions is whether optimistic bias exists among the target audience. For example, one student participant noted that he or she only thinks about diabetes when he or she goes home and sees the father taking insulin shots. It is necessary to identify whether this person considers him- or herself to be at risk for diabetes because it has been found that college students are more likely to think their peers are at risk for type 2 diabetes than to see themselves as being at risk (Reyes-Velázquez W, Sealey-Potts C, unpublished observations).
Participants analyzed three type 2 diabetes prevention messages designed for this age-group. Although some students liked positive affect messages, some preferred fear appeals. However, they disagreed with the message structure. As stated above, fear appeals must include a threat, evidence suggesting that the person is specifically vulnerable to the threat, and solutions that are easy to perform and effective.20 Participants requested more information to learn how the health condition used to create the fear appeal developed. Because many college students might not worry about diabetes because they might not be at imminent risk, it is advisable to apply the Elaboration Likelihood model of persuasion,29 which is a scientific theory that provides a way to persuade an audience or produce an attitude change, when designing the intervention. As prevention messages are designed, it is necessary to keep in mind that they must be pertinent to college students because some participants mentioned that they would not read information that is not relevant to them. Per participants' suggestions, to disseminate prevention information to college students, it would be worthwhile to use interpersonal communication, traditional media, and social networking Internet sites such as Facebook. Although social networking sites are popular among young people,30 it is necessary to identify how to correctly design persuasive prevention messages to be disseminated on these outlets. It is advised that messages sent out to college students should be in full color and use more than one font.
Designing future interventions
Because participants reacted to positive affect messages and fear appeals differently, it is recommended to identify whether students in other geographical regions would pay attention to information containing these elements. Like food marketers who use a variety of tactics to persuade consumers, those managing diabetes prevention campaigns must also pay close attention to what techniques, channels, and messages best resonate with each target audience.31
Because of the increasing use of social networking Internet sites, mobile communication devices such as smart phones and tablet computers, video-sharing sites, and immersive environments among college students and the flexibility of these digital devices and media,32 it is advisable to design interventions with a 360° strategy.33 Interventions applying a 360° strategy should connect with college students online through devices, platforms, and experiences that are engaging and relevant to them. Then, students should be encouraged to participate in offline activities designed for the intervention. If done through the right devices and platforms, there is a greater likelihood that college students will engage with the messages, in turn increasing the likelihood of intervention success.
Although efforts were made to recruit males and females, many men refused to participate in the study. Also, there is a possibility that the group discussion shaped participants' point of view about diabetes. Consequently, they might have provided erroneous information.
This research was supported by an enhancement research grant awarded by Sam Houston State University. The authors wish to acknowledge the help provided on this project by the Office of Research and Sponsored Programs, Sam Houston State University instructor Ruth Massingill, and students Cristine Rodriguez and Kathryn Rodgers.